Prevenção Da Aspiração Pulmonar Do Conteúdo Gástrico (Rev Bras Anestesiol, 2004)

Rev Bras Anestesiol
2004; 54: 2: 261 - 275
ARTIGO DE REVISO
REVIEW ARTICLE
Preveno da Aspirao Pulmonar do Contedo Gstrico *

Prevention of Pulmonary Gastric Contents Aspiration
Eduardo Toshiyuki Moro, TSA 1
RESUMO
Moro ET - Preveno da Aspirao Pulmonar do Contedo
Gstrico
JUSTIFICATIVA E OBJETIVOS: Apesar da baixa incidncia, a
aspirao pulmonar do contedo gstrico pode ter
conseqncias devastadoras para o indivduo. A diminuio na
funo do esfncter esofgico e dos reflexos protetores das
vias areas causadas pela depresso da conscincia,
predispe os pacientes a esta grave complicao. Neste artigo,
foi realizada uma reviso dos aspectos fisiolgicos associados
ao refluxo gastroesofgico, bem como os mtodos utilizados
para preveni-lo.
CONTEDO: So feitos comentrios sobre os mecanismos
envolvidos na aspirao do contedo gstrico, suas
conseqncias e mtodos de preveno, incluindo recentes
guias de jejum pr-operatrio elaborados aps reviso da
literatura, o uso racional de drogas que atuam no pH e volume
gstrico e, finalmente, o efeito de diferentes mtodos de
manuteno da via area na preveno da aspirao
pulmonar.
CONCLUSES: A aspirao pulmonar do contedo gstrico,
apesar de pouco freqente, exige cuidados especiais para sua
preveno. Guias de jejum pr-operatrio elaborados
recentemente sugerem perodos menores de jejum,
principalmente para lquidos, permitindo mais conforto aos
pacientes e menor risco de hipoglicemia e desidratao, sem
aumentar a incidncia de aspirao pulmonar perioperatria. O
uso rotineiro de drogas que diminuem a acidez e volume
gstrico parece estar indicado apenas para pacientes de risco.
O melhor mtodo de proteo da via area contra a aspirao
continua sendo a intubao traqueal. Outros mtodos de
manuteno da via area vm sendo adotados, mas a eficcia
na preveno da aspirao ainda i nferior, embora
representem importante alternativa em casos de falha de
intubao traqueal.
SUMMARY
Moro ET - Prevention of Pulmonary Gastric Contents Aspiration
BACKGROUND AND OBJECTIVES: Despite its low incidence, aspiration of pulmonary gastric contents may have devastating consequences. Esophageal sphincter function and
protective airway reflexes decrease caused by conscience depression, predisposes patients to this severe complication.
This article is a review of physiological aspects associated to
gastroesophageal reflux, as well as of the methods to prevent it.
CONTENTS: Comments are made about the mechanisms involved in gastric contents aspiration, its consequences and preventive methods, including recent preoperative fasting
guidelines developed after review of the literature, the reasonable use of drugs acting on gastric pH and volume, and finally
the effects of different airway control methods on pulmonary aspiration prevention.
CONCLUSIONS: Aspiration of pulmonary gastric contents, despite its low frequency, demands special preventive care. Recently developed preoperative fasting guidelines suggest
shorter fasting periods especially for liquids, allowing more
comfort to patients and less risk of hypoglycemia and dehydration, without increasing the incidence of perioperative pulmonary aspiration. The routine use of drugs decreasing gastric
acidity and volume seems to be indicated only for poor risk patients. The best method to protect airways against aspiration is
still tracheal intubation. Other airway control methods have
been adopted, but their efficacy in preventing aspiration is
lower, although representing major alternatives in cases of
intubation failure.
Key Words: COMPLICATIONS: pulmonary aspiration
Unitermos: COMPLICAES: aspirao pulmonar
INTRODUO
ecentes estudos sugerem que a aspirao pulmonar

perioperatria um evento pouco freqente, porm seu
impacto para o indivduo pode ser devastador 1 . Em 1946,
Mendelson j relacionava alimentao com aspirao pul* Recebido do (Received from) Hospital Santa Lucinda, Sorocaba, SP
1. Anestesiologista dos Hospitais Santa Lucinda e UNIMED; Instrutor do
CET do Conjunto Hospitalar de Sorocaba/PUC - SP
Apresentado (Submitted) em 01 de abril de 2003
Aceito (Accepted) para publicao em 24 de junho de 2003
Endereo para correspondncia (Correspondence to)
Dr. Eduardo T. Moro
Rodovia Raposo Tavares, Km. 113
Avenida Araoiaba SR 2 - US 85 - Condomnio Fazenda Lago Azul
18190-000 Araoiaba da Serra, SP
E-mail: edumoro@terra.com.br
Sociedade Brasileira de Anestesiologia, 2004
Revista Brasileira de Anestesiologia

Vol. 54, N 2, Maro - Abril, 2004
monar do contedo gstrico durante o parto com anestesia

geral. Ele descreveu duas sndromes: a primeira consistia
na inalao de alimentos slidos levando obstruo das
vias respiratrias e morte ou atelectasia macia. A segunda, que leva o seu nome, decorria da aspirao do contedo
gstrico lquido quando os reflexos larngeos estavam deprimidos por anestesia geral 2. Estes pacientes desenvolviam
cianose, taquicardia e taquipnia. Mendelson demonstrou
em coelhos que o desenvolvimento da sndrome dependia
do material aspirado ter pH cido 3 .
Neste artigo, os mecanismos envolvidos na regurgitao e
aspirao pulmonar do contedo gstrico so analisados
juntamente com alguns mtodos de preveno.
INCIDNCIA
Uma reviso na literatura sugere que a incidncia de aspirao pulmonar no perodo perioperatrio relativamente baixa e teve pequena mudana nos ltimos anos. Em 1986, um
261
MORO
estudo do Scandinavian Teaching Hospital observou que a

incidncia de aspirao variou entre 0,7 e 4,7 por 10.000
anestesias 4 . Uma publicao aps 10 anos observou que a
incidncia era de 2,5 por 10.000 no Norwegian Hospital 5 .
Estudos realizados na Clnica Mayo observaram incidncia
semelhante em adultos (3,1 por 10.000) 6 e crianas (3,8 por
10.000) 7 . Outro estudo realizado nos Estados Unidos observou uma incidncia maior em crianas (10,2 por 10.000) 8 .
A freqncia varia muito entre os pacientes. Assim, os idosos, os pacientes com estado fsico (ASA) de classificao
mais alta, as gestantes, os portadores de refluxo gastroesofgico, os obesos e os pacientes submetidos a cirurgia de urgncia apresentam maior risco de aspirao 1,9 . Alm disso,
dor, ansiedade, diabetes mellitus, insuficincia renal, depresso do nvel de conscincia, lcool e drogas (opiides,
benzodiazepnicos, anticolinrgicos) retardam o esvaziamento gstrico 3,9 .
Baseada em dados recentes disponveis, a aspirao pulmonar do contedo gstrico parece ser apenas discretamente mais freqente em crianas quando comparada incidncia nos adultos. As crianas ainda parecem ser menos gravemente afetadas pela aspirao 10 .
MORBIDADE E MORTALIDADE
A morbidade atribuda aspirao caracterizada pela presena de infiltrados pulmonares radiografia de trax, necessidade de uso de antibiticos ou broncodilatadores e
durao do suporte ventilatrio 9 (Tabela I). Em estudo realizado na Clnica Mayo 6 , 27% dos pacientes que aspiraram,
necessitaram suporte ventilatrio por mais de 24 horas.
Tabela I - Evoluo dos Pacientes com Aspirao Pulmonar
do Contedo Gstrico (Clnica Mayo)
Adulto (%)
Criana (%)
Nmero
215.488
63.180
Aspirao
67 (0,03)
24 (0,04)
Sintomas
24 (36)
9 (38)
Unidade de terapia intensiva
18 (27)
6 (25)
6 (9)
6 (25)
3 (4,5)
Ventilao mecnica *
bitos
Flick: Curr Opin Anesthesiol, 2002;15:323-327

* Por mais de 24 horas
Grandes estudos retrospectivos realizados em diferentes

centros mostraram que a taxa de mortalidade variou de zero
a 4,5% 4-8 .
No Reino Unido, o Inqurito Confidencial sobre bitos Maternos apresentou dados acurados sobre a mortalidade
aps aspirao do contedo gstrico na prtica obsttrica de
1957 a 1998 11 .
Das causas de morte atribudas anestesia, a proporo decorrente da aspirao pulmonar tem declinado progressivamente de 50% a 65% h 50 anos, para at 12% nos ltimos 10
262
anos. Esta diminuio , sem dvida, resultado da transio

da anestesia geral para os bloqueios espinhais na prtica
anestsica em obstetrcia 11 .
FISIOLOGIA
Os mecanismos fisiolgicos que previnem a regurgitao e a
aspirao do contedo gstrico incluem o esfncter esofgico inferior, o esfncter esofgico superior e os reflexos
larngeos.
Contedo Gstrico
Os valores crticos para o risco de pneumonite aspirativa, derivados de modelos animais, so volume do contedo gstrico maior que 0,4 ml.kg-1 e pH menor que 2,5 12 . Porm, estudo realizado em gatos mostra que o volume gstrico necessrio para produzir regurgitao espontnea foi 20,8 ml.kg-1 13.
Outros investigadores consideraram volume gstrico residual entre 0,8 e 8 ml.kg-1 para ser considerado como fator de
risco para aspirao 13-16 .
Um exame crtico da literatura revela que a diminuio do pH
e o aumento do volume gstrico so importantes fatores de
risco para aspirao pulmonar em modelos animais. Porm,
diferenas entre as espcies tornam a extrapolao para humanos difcil e imprecisa 17 . Alm disso, pacientes saudveis
com jejum pr-operatrio prolongado, freqentemente apresentam volume gstrico maior que 0,4 ml.kg-1 e pH menor
que 2,5 18-21 .
Assim, apesar de haver evidncias de uma relao direta entre volume aspirado e gravidade da pneumonite 14 , a relao
entre volume gstrico e volume aspirado tem sido contestada e a sua validade necessita de mais estudos para ser esclarecida 22 .
Em 1833, Beaumont j registrava que, aps ingesto de lquidos, o esvaziamento do estmago ocorria em menos de 1
hora, enquanto o tempo de esvaziamento para os slidos era
muito mais longo 23 . A dependncia da motilidade gstrica
para o esvaziamento de material slido explica esta diferena, j que, no caso dos lquidos, esta dependncia no ocorre
24
. gua e fluidos passam pelo estmago rapidamente. Metade de um bolus de 500 ml de soluo fisiolgica isotnica
esvaziada e/ou absorvida pelo estmago humano em 12 minutos 25,26 . Metade de um bolus de 750 ml desaparece do estmago em 20 minutos 21,27,28 e 80% a 95% dos lquidos ingeridos desaparecem em uma hora 29,30 .
Entretanto, o tempo de esvaziamento gstrico para slidos
varia consideravelmente.
Entre os tipos de alimentos ingeridos, o esvaziamento dos lipdeos mais lento, o das protenas mais rpido e o dos carboidratos, intermedirio 31 . No existe uma definio absoluta para alimento slido. Em termos prticos, slidos so alimentos que se encontram neste estado no estmago 23 .
Assim, a gelatina slida antes da ingesto, mas se encontra
no estado lquido no estmago. Por outro lado, o leite forma
componentes slidos no interior do estmago, levando
horas para seu esvaziamento.
PREVENO DA ASPIRAO PULMONAR DO CONTEDO GSTRICO
Esfncter Esofgico Inferior

Aparentemente, no h um verdadeiro esfncter anatmico,
mas as fibras musculares da juno entre o esfago e o estmago se dispem em forma circular, funcionando como
esfncter verdadeiro.
A tendncia regurgitao no depende diretamente da
presso do esfncter esofgico inferior, mas da diferena entre esta e a presso intra-gstrica. Antiemticos, drogas colinrgicas, succinilcolina e anti-cidos aumentam a presso
do esfncter esofgico inferior, enquanto anticolinrgicos, tiopental, opiides e anestsicos inalatrios a reduzem. Atracrio, vecurnio, ranitidina e cimetidina no tm efeito no esfncter esofgico inferior 32
Esfncter Esofgico Superior
Ajuda a prevenir a aspirao pela ao na transio entre o
esfago e a hipofaringe exercida pelo msculo cricofarngeo. Durante a anestesia e mesmo sono normal, sua funo
e tnus esto alterados 33 .
Com exceo da cetamina, drogas anestsicas reduzem o
tnus do esfncter esofgico superior. Alm disso, pacientes
que receberam agentes bloqueadores neuromusculares podem estar sob risco de aspirao, mesmo com TOF (Train of
Four) de 0,7, pois o tnus do esfncter esofgico superior ainda se encontra diminudo, assim como a deglutio 34-36 .
Reflexos Larngeos
Os reflexos das vias areas protegem os pulmes da aspirao. Existem 4 reflexos bem definidos 10 : apnia com laringoespasmo, tosse, expirao (expirao forada sem inspirao precedendo) e a Spasmodic Panting (respirao superficial com freqncia de 60 movimentos por minuto por
menos de 10 segundos).
Duas horas aps a recuperao de uma anestesia geral, em
casos ambulatoriais, a sensibilidade dos reflexos das vias
areas superiores no havia retornado ao normal 37 . A reduo destes reflexos parece estar presente no apenas no intra-operatrio, mas tambm nos pacientes sob efeito de medicao pr-anestsica e no ps-operatrio, talvez por perodo mais longo do que se estimava. Alm disso , os idosos
tm reflexos das vias areas menos ativos e devem ser considerados como risco aumentado para aspirao 37-40 .
PREVENO
Mtodos utilizados para prevenir a aspirao pulmonar envolvem o controle do contedo gstrico, reduo do refluxo
gastroesofgico e proteo das vias areas. Isto obtido
atravs do jejum pr-operatrio, diminuio da acidez gstrica, estmulo ao esvaziamento gstrico e manuteno da
competncia do esfncter esofgico 41 . A proteo das vias
areas requer presso na cartilagem cricide (manobra de
Sellick) 42 , posicionamento adequado do paciente, intubao traqueal sob induo com seqncia rpida ou acordado
e aspirao da sonda nasogstrica antes da induo da

anestesia 43 .
CONTROLE DO CONTEDO GSTRICO
Jejum Pr-Operatrio
O objetivo do jejum pr-operatrio diminuir o risco e o grau
de regurgitao do contedo gstrico, prevenindo assim a
aspirao pulmonar e suas conseqncias.
A antiga orientao Nada por boca aps meia-noite tem
sido substituda por perodos menores de jejum pr-operatrio. Existem vrios benefcios quando pacientes, principalmente as crianas, ingerem lquidos antes da anestesia, incluindo aumento da satisfao e diminuio da irritabilidade,
aumento do pH gstrico, diminuio do risco de hipoglicemia
liplise e desidratao 15,21,44-46 .
Estudos em diferentes centros, envolvendo crianas que ingeriram diferentes tipos de lquidos sem resduos (gua,
ch, caf, suco de fruta sem polpa, todos sem lcool e com
pouco acar) em volumes variveis, concluram que a ingesto de lquidos, sem limite de volume, pode ser permitida,
com segurana, 2 horas ou mais antes da cirurgia 23,47 .
Normalmente, o ritmo de produo de secreo cida do estmago de 0,6 ml.kg-1 .h-1 21 , mas pode chegar a at 500
ml.h-1 com o jejum e a fome 19,30,48 . Foi observada, em muitos
casos, diminuio do pH gstrico com o aumento da durao
do jejum pr-operatrio 49 . A ansiedade um estmulo emocional que pode aumentar a produo de HCl, de forma similar
fase ceflica da secreo gstrica 17,48,50,51 , o que explica o
aumento do volume e a diminuio do pH gstrico aps jejum
prolongado 17,27,49,52,53 . O aumento do pH gstrico dos pacientes que receberam lquidos 2 a 3 horas antes da interveno cirrgica pode ser resultado de diluio das secrees
cidas e/ou decrscimo na sua produo pela diminuio
dos nveis de ansiedade e fome. A diminuio no volume gstrico nos pacientes que receberam lquido poucas horas antes da cirurgia pode ser devida estimulao da motilidade
gstrica causada pela entrada de lquido frio e/ou pela distenso fsica do estmago 15,17,27,54 .
Apesar do conhecimento acumulado at hoje, no possvel
predizer com certeza o contedo gstrico. Pacientes saudveis com jejum prolongado podem, no dia da cirurgia, apresentar vmito com contedo da refeio do dia anterior. Outros podem apresentar hipoglicemia, desidratao e irritabilidade. Parece razovel, porm, concluir que a ingesto irrestrita de lquidos claros, para pacientes saudveis, 2 horas
ou mais antes da cirurgia tem relao risco-benefcio mais do
que aceitvel 7,8,11,21,55,56 .
A American Society of Anesthesiologists, atravs da ASA
Task Force on Preoperative Fasting 57 , desenvolveu um guia
prtico para o jejum pr-operatrio e para o uso de drogas envolvidas na diminuio do volume e da acidez gstrica. Baseado em extensa reviso da literatura, o guia se refere a pacientes saudveis, de todas as idades, submetidos a procedimentos eletivos, sem incluir pacientes com maior risco de aspirao. Tais recomendaes podem ser adotadas, modifi263
MORO
cadas ou rejeitadas de acordo com as necessidades clnicas

individuais e esto sujeitas a revises peridicas de acordo
com a evoluo do conhecimento sobre o assunto.
As recomendaes esto resumidas a seguir (Tabela II):
Lquidos sem resduos (gua, ch, caf, suco de fruta
sem polpa, todos sem lcool e com pouco acar): jejum
de 2 horas para todas as idades;
Leite materno: jejum de 4 horas para recm-nascidos e
lactentes;
Dieta leve (ch e torradas) e leite no materno: aceita-se
at 6 horas de jejum para crianas e adultos;
Frmula infantil: jejum de 6 horas para recm-nascidos e
lactentes;
Slidos: jejum de 8 horas para crianas e adultos.
Tabela II - Recomendaes para Jejum Pr-Operatrio Segundo a ASA Task Force on Preoperative Fasting
Alimento Ingerido
Jejum Mnimo (h)
Lquido sem resduos
Leite materno
Frmula infantil
Leite no materno
Dieta leve
Summary of Fasting Recommendations to Reduce the Risk of Pulmonary

Aspiration. From: Anesthesiology, 1999;90:896-905.
Muitos investigadores tm estudado a implementao dos

novos guias de jejum pr-operatrio que substituram a antiga orientao Nada por boca aps a meia-noite. Ferrari 58
avaliou 51 instituies nos Estados Unidos e Canad e concluiu que a conduta preconizada pela American Society of
Anesthesiologists representa a maioria das instituies para
crianas na Amrica do Norte. Investigaes realizadas na
Inglaterra, Esccia, Alemanha e Noruega tambm mostraram que medidas mais flexveis com relao ao jejum
pr-operatrio tm sido adotadas pela maioria das instituies daqueles pases, sem aumento nas complicaes 59-62 .
Alguns pontos ainda devem ser mencionados:
Estudos em adultos mostraram que no houve diferena no
contedo gstrico de pacientes que mascaram goma de
mascar sem acar imediatamente antes da cirurgia 16,63 .
Ainda assim, Splinter 23 sugere jejum de 2 horas para goma
de mascar e balas.
Estudo recente em gestantes saudveis, de termo, no obesas e que no estavam em trabalho de parto no encontrou
diferena no contedo gstrico aps ingesto de 300 ml de
gua quando comparado ao contedo daquelas com jejum
prolongado 64 .
A American Society of Anesthesiologists Task Force on
Obstetrical Anesthesia 65 recomenda que a ingesto moderada de lquidos sem resduos pode ser permitida para gestantes em trabalho de parto no complicado. Nos casos em
264
que h outro fator de risco associado (diabetes, obesidade

mrbida, via area difcil), ou pacientes com risco elevado
para evoluo para parto cesariano, deve haver restrio lquida determinada caso a caso. Com relao aos slidos, a
comisso concorda que o perodo de 8 horas ou mais para cesarianas eletivas o mais apropriado. Pacientes em trabalho
de parto no devem ingerir slidos.
Os mecanismos envolvidos no aumento do risco de aspirao pulmonar em obesos no incluem o aumento do volume
gstrico, pois este no maior quando comparado ao volume
dos no obesos. Outro fatores, como as presses intra-gstrica, abdominal e do esfncter esofgico inferior, provavelmente, desempenhem um papel mais importante na fisiopatologia da aspirao em obesos 66 .
Segundo a Norwegian National Consensus, a medicao
pr-anestsica pode ser ingerida com 150 ml de gua, em
adultos, at 1 hora antes da anestesia. O mesmo vale para as
crianas, mas com limite de 75 ml de gua 23 .
Reduo da Acidez Gstrica
Na prtica anestsica, muitos estudos clnicos tm sido realizados sobre o uso de antagonistas do receptor H2 e bloqueadores da bomba de prtons em pacientes saudveis para
avaliar seus efeitos no pH e volume gstrico 67 .
A administrao de dose nica de 150 mg de ranitidina, poucas horas antes da induo da anestesia, aumenta significativamente o pH gstrico, alm de reduzir seu volume 67-69 .
A prescrio de bloqueadores da bomba de prtons, porm,
exige o conhecimento de sua farmacologia. Estudos tm
mostrado que estas drogas so mais efetivas se administradas em duas doses sucessivas: uma na noite anterior e outra
na manh da anestesia 67-69 .
Apesar de ser possvel demonstrar que estas drogas aumentam o pH gstrico e diminuem o seu volume, a ASA Task Force considera que no existem evidncias que apoiem seu
uso rotineiro em pacientes saudveis, mas apenas em pacientes de risco, j que no h diminuio comprovada na incidncia de aspirao, morbidade ou mortalidade com o uso
destas drogas nos pacientes saudveis 57
A eficcia da administrao de anti-cidos no pr-operatrio
para diminuir a acidez gstrica est comprovada, mas no
existem evidncias de que estas solues atuem no volume
gstrico. Anti-cidos particulados podem aumentar o risco
de leso pulmonar se houver aspirao; portanto, devem ser
evitados. Assim, os anti-cidos (no particulados como o citrato de sdio) no pr-operatrio, s esto indicados para pacientes de risco 57 .
Os antiemticos (p. ex.: droperidol e ondansetron) tambm
esto indicados somente para os casos de maior risco de aspirao 57 .
Sonda Nasogstrica
comum a prtica de insero de sonda nasogstrica nos
pacientes de risco antes da anestesia, com o objetivo de esvaziar o estmago. Porm, parece que a funo dos esfncteRevista Brasileira de Anestesiologia
PREVENO DA ASPIRAO PULMONAR DO CONTEDO GSTRICO
res esofgicos superior e inferior fica comprometida quando

comparada funo nos pacientes sem a sonda nasogstrica 42,70 . Sellick recomenda, em seu trabalho original 42 , que a
sonda seja retirada antes da induo da anestesia. Porm,
dois estudos em cadveres mostraram que a eficcia da manobra de Sellick no est diminuda com a sua presena 71,72 .
Assim, a sonda funcionaria como uma passagem segura do
contedo gstrico quando uma compresso eficaz na cartilagem cricide fosse aplicada. Com base nestes dados, Smith 9
sugere que a sonda seja deixada in situ durante aplicao de
induo de seqncia rpida associada manobra de
Sellick.
No existem diferenas significativas na incidncia de aspirao pulmonar quando diferentes calibres de sonda nasogstrica so utilizadas 73 .
Um balo associado sonda tem sido empregado com sucesso, buscando ocluir a crdia e, portanto o refluxo gastroesofgico 74 . Esta sonda com balo gstrico tem sido estudada em conjunto com a mscara larngea. Observou-se
que a sonda no interferia com a insero da mscara larngea e que esta no impedia a insero da sonda. Esta
associao representa uma boa opo para manipulao
de vias areas difceis em pacientes sob risco de aspirao 75 .
Presso na Cartilagem Cricide
A presso na cartilagem cricide (manobra de Sellick) se tornou prtica universal durante induo de anestesia em pacientes potencialmente com estmago cheio 76 . Tal manobra,
quando bem realizada, previne a insuflao gstrica em crianas 77 e em adultos 78,79 , alm de aumentar o tnus do esfncter esofgico superior 80 . O tnus do esfncter esofgico
inferior diminui com esta compresso 81 , o que sugere a presena de mecanorreceptores na faringe que promovem um
relaxamento reflexo deste esfncter. Este efeito, porm, parece no provocar refluxo gastroesofgico 82 .
A aplicao incorreta da manobra pode causar deformidade
da cartilagem cricide, fechamento das cordas vocais e dificuldade de ventilao, especialmente em mulheres 83 . A fora aplicada deve ser suficiente para prevenir a aspirao,
mas no to grande a ponto de causar obstruo das vias areas ou permitir ruptura esofgica, caso haja vmito. A direo ceflica e para trs da fora aplicada parece melhorar a
visualizao atravs da laringoscopia 84 .
Um importante cenrio a ser considerado a falha de intubao traqueal em paciente com estmago cheio sob compresso da cartilagem cricide. Nesta situao, a mscara larngea pode facilitar a ventilao e oxigenao, mas estudos
mostram que a manobra de Sellick impede o seu correto posicionamento 85,86 . Assim, se a utilizao da mscara larngea
for feita durante falha na intubao traqueal, pode ser necessria a interrupo da manobra temporariamente para facilitar a ventilao, oxigenao e intubao atravs da mscara
larngea. Interrupo parece ser uma opo razovel, j que
a compresso da cartilagem cricide pode se tornar ineficaz
aps poucos minutos de aplicao 87 .
EFEITO DOS DIFERENTES MTODOS DE CONTROLE

DA VIA AREA SOBRE O RISCO DE ASPIRAO
Intubao Traqueal
A intubao traqueal o mtodo mais eficaz de proteo
das vias areas em pacientes anestesiados. Porm, em alguns estudos realizados em pacientes intubados na unidade de terapia intensiva, o balonete de grande volume e baixa presso permitiu o vazamento de corante para a traquia
88,89
. O mecanismo envolvido talvez seja a microaspirao
atravs da glote por pequenos canais entre o balonete e a
mucosa da traquia 90 . A lubrificao destes balonetes com
gel lubrificante demonstrou diminuir significativamente o
vazamento 90,91 .
Mscara Larngea
O uso da mscara larngea est associada a uma reduo na
barreira pressrica representada pelo esfncter esofgico inferior 92 . Anlise de pacientes sob anestesia geral com ventilao sob presso positiva mostrou que, no grupo em que foi
utilizada a mscara larngea, houve aumento significativo de
episdios de refluxo gastroesofgico quando comparado ao
grupo que utilizou tubo traqueal com balonete 93 . O refluxo
tambm est presente em pacientes em ventilao espontnea com mscara larngea 94 . Na verdade, no existe diferena significativa na incidncia de regurgitao entre grupos
ventilando espontaneamente, ou sob ventilao com presso positiva 95,96 . O momento da remoo da mscara larngea, no fim da anestesia geral, parece influenciar na incidncia de refluxo, j que aqueles que tiveram a mscara removida quando capazes de abrir a boca espontaneamente, tiveram incidncia de refluxo menor que aqueles que tiveram a
mscara removida antes da recuperao da conscincia 97 .
O desenvolvimento de um novo modelo de mscara larngea, ProSeal (Laryngeal Mask Company, Henley on Thames, UK) permite, atravs de uma abertura esofgica, a passagem de sonda orogstrica para melhor drenagem do contedo gstrico, alm de melhor bloqueio insuflao gstrica durante a ventilao com presso positiva. Estudo recente mostra que a ProSeal mais eficaz que a tradicional mscara larngea na preveno do refluxo, o que a torna uma boa
opo para pacientes com risco de aspirao e com falha de
intubao traqueal 98,99 .
COPA e Combitube
A COPA (Cuffed oropharyngeal airway) menos eficaz ainda que a mscara larngea na preveno da regurgitao 100 ,
no sendo, portanto, indicada para pacientes com risco de
aspirao.
O combitube, apesar de promover proteo contra regurgitao e permitir drenagem do contedo gstrico, requer profissional treinado para sua utilizao, j que seu uso est associado a complicaes como dor de garganta, disfagia e formao de hematoma. Assim, em situaes de emergncia,
265
MORO
quando a proteo da via area necessria, os benefcios

do combitube devem ser balanceados com as possveis
complicaes associadas 9 .
OUTRAS MEDIDAS DE PREVENO DA
ASPIRAO GSTRICA
Previso de Intubao Traqueal Difcil
O primeiro passo do algoritmo da via area difcil, elaborado
pela American Society of Anesthesiologists, a identificao
dos pacientes com provvel intubao traqueal difcil 101 . Em
alguns casos como trauma de face, certas sndromes congnitas, obesidade mrbida, a dificuldade pode ser identificada
com facilidade. Porm, nos casos no evidentes, a dificuldade de intubao pode se manifestar apenas aps a induo
da anestesia geral, quando os reflexos protetores esto abolidos, expondo o paciente ao risco de aspirao. Assim, a
previso de intubao difcil pode ser realizada atravs de alguns parmetros, como o teste de Mallampati 102 , distncia tireomentoniana ou outros testes disponveis na literatura 103 .
H 50 anos na prtica clnica, a succinilcolina tem sido utilizada pela maioria dos anestesiologistas como o bloqueador
neuromuscular de escolha para intubao de pacientes de
estmago cheio, j que a droga que melhor preenche os critrios citados acima. Porm, complicaes como o desencadeamento da hipertermia maligna, hipercalemia fatal, bradiarritimias, aumento das presses intra-gstrica e intra-ocular tm estimulado a pesquisa de bloqueadores neuromusculares no despolarizantes com menor latncia e durao,
sem os efeitos colaterais da succinilcolina. Da a introduo
do rocurnio como alternativa nos pacientes de risco para aspirao pulmonar. Para garantir latncia e condies de intubao semelhantes a succinilcolina, a dose preconizada de
1 mg.kg-1 ou mais, o que implica durao maior, dificultando
seu uso em procedimentos curtos ou naqueles com possibilidade de intubao traqueal difcil 105-108 .
O uso da succinilcolina ou rocurnio, intubao com paciente acordado, o uso da fibroscopia etc., tm suas vantagens e
desvantagens. Em cada caso, o anestesiologista quem
deve julgar qual a melhor alternativa para a segurana do paciente sob risco de aspirao pulmonar 109 .
PNEUMONITE ASPIRATIVA
Os pacientes com risco de aspirao devem ser colocados

em posio horizontal com dorso elevado em torno de 30 em
relao ao restante do corpo. Esta posio evitar a regurgitao, mas caso acontea, deve-se mudar imediatamente a
posio da mesa de maneira que a cabea fique posicionada
abaixo do tronco, evitando-se aspirao.
Aspirao pulmonar definida como a inalao de contedo da orofaringe ou estmago atravs da laringe para o trato respiratrio baixo 110,111 . Vrias sndromes pulmonares
podem ocorrer aps aspirao, dependendo da quantidade e da natureza do material. A pneumonite aspirativa (sndrome de Mendelson) a leso qumica causada pela inalao de contedo gstrico estril, enquanto pneumonia
aspirativa um processo infeccioso causado pela inalao de material colonizado, proveniente principalmente
da orofaringe. Outras sndromes incluem obstruo mecnica das vias areas, abscesso pulmonar e fibrose intersticial crnica 110,111 .
A aspirao de material gstrico causa intenso processo inflamatrio pulmonar. O paciente pode apresentar tosse, sibilos, taquipnia, cianose, edema pulmonar, hipoxemia e
hipotenso, com rpida progresso para Sndrome da angstia respiratria e morte. Muitos pacientes podem apresentar apenas tosse ou sibilos ou diminuio da saturao
de oxignio associada a evidncias radiolgicas de aspirao 112 .
O tratamento inclui administrao de oxignio ou suporte
ventilatrio quando necessrio. O uso de antibitico profiltico no est indicado, pois pode tornar o paciente suscetvel
infeco secundria por organismos mais resistentes. Aantibioticoterapia est indicada em pacientes com pneumonite
aspirativa e falha na resoluo do quadro, 48 horas aps a
aspirao 113 . Corticosterides no so recomendados, pois
estudos multicntricos, aleatrios e controlados falharam
em provar seu benefcio 114,115 .
A broncoscopia deve ser realizada nos pacientes sob suspeita de aspirao de material slido que cause obstruo de
vias areas. A lavagem pulmonar sob viso direta tambm
est indicada para aspirao de material slido 3 .
Posicionamento do Paciente
INTUBAO TRAQUEAL COM PACIENTE ACORDADO

OU SOB INDUO DE SEQNCIA RPIDA
Paciente acordado
Uma vez identificada uma provvel via area difcil, a forma
mais segura de intubao com o paciente consciente e em
ventilao espontnea 103 .
A intubao traqueal pode ser realizada aps leve sedao,
mantendo os reflexos protetores das vias areas. Deve-se administrar antissialogogo, como atropina ou escolpolamina, e
realizar anestesia tpica na orofaringe com lidocana spray
(10%). Bloqueio do nervo glossofarngeo e larngeo superior
pode ser til para aqueles que dominam a tcnica 101.
Seqncia Rpida
A induo com a tcnica de seqncia rpida envolve, tradicionalmente, preparo do equipamento que deve incluir, alm
do material para intubao traqueal, um aspirador e um laringoscpio de reserva e equipamento para possvel falha de intubao (mscara larngea, fastrack, fibroscpio); ofertar
oxignio a 100% sob mscara facial por 1 minuto; opiide e
anestsico venoso de curta latncia e durao (p. ex.: propofol e alfentanil) e finalmente um bloqueador neuromuscular,
tambm com curta latncia e durao 3,104 .
266

PREVENTION OF PULMONARY GASTRIC CONTENTS ASPIRATION
CONCLUSES
A aspirao pulmonar do contedo gstrico, apesar de pouco freqente, exige cuidados especiais para sua preveno.
Guias de jejum pr-operatrio elaborados recentemente sugerem perodos menores de jejum, principalmente para lquidos, permitindo mais conforto aos pacientes e menor risco de
hipoglicemia e desidratao, sem aumentar a incidncia de
aspirao pulmonar perioperatria. O uso rotineiro de drogas que diminuem a acidez e volume gstrico parece estar indicado apenas para pacientes de risco. O melhor mtodo de
proteo da via area contra a aspirao continua sendo a intubao traqueal. Outros mtodos de manuteno da via area vm sendo adotados, mas a eficcia na preveno da aspirao ainda inferior, embora representem importante alternativa em casos de falha de intubao traqueal. A presso
na cartilagem cricide, a induo com tcnica de seqncia
rpida ou com paciente acordado, alm do posicionamento
do paciente, exercem papel importante na preveno da
aspirao pulmonar.
Prevention of Pulmonary Gastric Contents

Aspiration
Eduardo Toshiyuki Moro, TSA, M.D.
INTRODUCTION
Recent studies have suggested that perioperative pulmonary aspiration is an uncommon event however with devastating impact 1 . In 1946, Mendelson has already established a
relationship between feeding and aspiration of pulmonary
gastric contents during labor under general anesthesia. He
has described two syndromes: the first would be the inhalation of solid food leading to airways obstruction and death or
massive atelectasis. The second, named after him, would be
liquid contents aspiration when laryngeal reflexes are depressed by general anesthesia 2 . These patients would develop cyanosis, tachycardia and tachypnea. Mendelson has
shown in rabbits that the development of the syndrome would
depend on the acid pH of aspired material 3 .
In this article, mechanisms involved in regurgitation and aspiration of pulmonary gastric contents are evaluated together
with some preventive methods.
INCIDENCE
A review of the literature suggests that the incidence of
perioperative pulmonary aspiration is relatively low and has
suffered minor changes in recent years. In 1986, a study of
the Scandinavian Teaching Hospital has observed that the incidence of aspiration varied from 0.7 to 4.7 per 10 thousand
anesthesias 4 . A publication 10 years later has observed an
incidence of 2.5 per 10 thousand in the Norwegian Hospital 5 .
Mayo Clinic studies have observed similar incidence in adults

(3.1 per 10 thousand) 6 and children (3.8 per 10 thousand) 7 .
Another North-American study has observed a higher incidence in children (10.2 per 10 thousand) 8 .
Frequency varies widely among patients. So, elderly, higher
ASA physical status patients, pregnant women, patients suffering from gatroesophageal reflux, obese and patients submitted to urgency surgeries are at higher risk for aspiration 1,9 .
In addition, pain, anxiety, diabetes mellitus, renal failure, conscience depression, alcohol and drugs (opioids,
benzodiazepines, anticholinergic) which delay gastric emptying 3,9 .
Based on recently available data, pulmonary gastric contents
aspiration seems to be only slightly more frequent in children
as compared to adults. Children also seem to be less severely
affected by aspiration 10 .
MORBIDITY AND MORTALITY
Morbidity attributed to aspiration is characterized by the presence of pulmonary infiltrates at chest X-rays, by the need for
antibiotics or bronchodilators and by ventilatory support duration 9 (Table I).
Table I - Evolution of Patients with Pulmonary Gastric Contents Aspiration (Mayo Clinic)
Adults (%)
Children (%)
Number
215,488
63,180
Aspiration
67 (0.03)
24 (0.04)
Symptoms
24 (36)
9 (38)
Intensive care unit
18 (27)
6 (25)
6 (9)
6 (25)
3 (4.5)
Mechanical ventilation *
Deaths
Flick: Curr Opin Anesthesiol, 2002;15:323-327

* For more than 24 hours
In a Mayo Clinic study 6 , 27% of pulmonary aspiration patients

needed ventilatory support for more than 24 hours.
Major retrospective studies performed in different centers
have shown mortality rates varying from zero to 4.5% 4-8 .
In the UK, the Confidential Enquirer into Maternal Deaths
has presented accurate data on post-gastric content aspiration mortality in obstetrics, from 1957 to 1998 11 . For anesthesia-related deaths, the proportion attributed to pulmonary aspiration has progressively decreased from 50% to 65% fifty
years ago, to up to 12% in recent 10 years. This decrease is
clearly the result of replacing general anesthesia by spinal
blocks in obstetric anesthesia 11 .
PHYSIOLOGY
Physiological mechanisms preventing gastric contents regurgitation and aspiration include lower esophageal
sphincter, upper esophageal sphincter and laryngeal reflexes.
267
MORO
Gastric Contents
Critical values for aspiration pneumonitis risk derived from
animal models are gastric contents volume above 0.4 ml.kg-1
and pH lower than 2.5 12 . However, a study performed with
cats has shown that gastric volume necessary for spontaneous regurgitation was 20.8 mL.kg-1 13 . Other investigators
consider residual gastric volume between 0.8 and 8 mL.kg-1
as a risk factor for aspiration 13-16 .
A critical review of the literature has revealed that lower pH
and higher gastric volume are major risk factors for pulmonary aspiration in animal models. However, differences
among species make human extrapolation difficult and inaccurate 17 . In addition, healthy patients with prolonged preoperative fasting often have gastric volume above 0.4 mL.kg-1
and pH below 2.5 18-21 .
So, in spite of evidences of direct relationship between aspired volume and pneumonitis severity 14 , the ratio between
gastric and aspired volume has been questioned and its validity needs further studies 22 .
In 1833, Beaumont has already recorded that after fluid ingestion, stomach would empty in less than 1 hour, while emptying time for solids was much longer 23 . The dependence on
gastric motility for solid material emptying explains this difference, since in case of fluids there is no such dependence 24 .
Water and fluids cross the stomach very fast. Half of 500 ml
isotonic saline solution bolus is emptied and/or absorbed by
the stomach in 12 minutes 25,26 . Half of 750 ml bolus disappears in 20 minutes 21,27,28 and 80% to 95% of ingested fluids
disappear in one hour 29,30 .
However, gastric emptying time for solids varies considerably.
Among types of ingested food, lipids emptying is slower, proteins emptying is faster and carbohydrates emptying is intermediate 31 . There is no absolute definition of solid food. In
practical terms, solid is every food in this state in the stomach
23
. So, gelatin is solid before ingestion, but is not in solid state
in the stomach. On the other hand, milk forms solid components in the stomach and takes hours to be emptied.
Lower Esophageal Sphincter
Seemingly there is no true anatomic sphincter, but muscle fibers of the junction of esophagus and stomach, which are disposed in circle acting as a true sphincter.
The trend to regurgitation is not directly dependent on lower
esophageal sphincter pressure, but on the difference between
this pressure and intra-gastric pressure. Antiemetics,
cholinergic drugs, succinylcholine and antacids increase
lower esophageal sphincter pressure, while anticholinergics,
thiopental, opioids and inhalational anesthetics decrease it.
Atracurium, vecuronium, ranitidine and cimetidine have no effect on lower esophageal sphincter 32.
Upper Esophageal Sphincter
Helps preventing aspiration by acting on the transition exerted by the cricopharyngeal muscle between esophagus
268
and hypopharynx. During anesthesia, and even during normal sleep, there is a change in its function and tone 33 .
With the exception of ketamine, anesthetic drugs decrease
upper esophageal sphincter tone. In addition, patients receiving neuromuscular blockers may be at risk of aspiration, even with TOF (train of four) of 0.7, because upper
esophageal sphincter tone and swallowing are still decreased 34-36 .
Laryngeal Reflexes
Airway reflexes protect lungs against aspiration. There are
four well-defined reflexes 10 : apnea with laryngospasm,
cough, expiration (forced expiration without preceding inspiration) and Spasmodic Panting (superficial breathing with
frequency of 60 movements per minute for less than 10 seconds).
Two hours after outpatient general anesthesia recovery, upper airway reflexes sensitivity has not returned to normal 37 .
This decrease in reflexes seems to be present not only in the
intraoperative period, but also in premedicated patients and
in the postoperative period, probably for a long than expected
period. In addition, elderly people have less active airway reflexes and should be considered at increased risk for aspiration 37-40 .
PREVENTION
Methods to prevent pulmonary aspiration include gastric
contents control, gastroesophageal reflux decrease and airway protection. This is achieved with preoperative fasting,
gastric acidity decrease, gastric emptying stimulation and
esophageal sphincter competence maintenance 41 . Airway
protection requires cricoid cartilage pressure (Sellicks maneuver) 42 , adequate patient positioning, tracheal intubation
under rapid sequence induction or with awaken patient and
nasogastric tube aspiration before anesthetic induction 43 .
GASTRIC CONTENTS CONTROL
Preoperative Fasting
The objective of preoperative fasting is to decrease gastric
contents regurgitation risk and degree, thus preventing pulmonary aspiration and its consequences.
The old orientation nothing by mouth after midnight has
been replaced by shorter preoperative fasting periods. There
are several benefits when patients, especially children, ingest fluids before anesthesia, including higher satisfaction
and less irritability, gastric pH increase, decreased risk for
lipolysis hypoglycemia and dehydration 15,21,44-46 .
Studies in different centers involving children ingesting different types of clear fluids (water, tea, coffee, fruit juice without
pulp, all without alcohol and with little sugar) in variable volumes have concluded that fluid ingestion, without volume
limitation, may be safely allowed 2 hours or more after surgery 23,47 .
In general, stomach acid secretion production rate is 0.6

mL.kg-1 .h-1 21 , but it may reach 500 ml.h-1 with fasting and hunger 19,30,48 . It has been observed in many cases a decrease in
gastric pH with increased preoperative fasting duration 49 .
Anxiety is an emotional stimulation able to increase HCI production, similarly to the cephalic phase of gastric secretion
17,48,50,51
, which explains increased volume and decreased
gastric pH after prolonged fasting 17,27,49,52,53 . Increased gastric pH in patients receiving fluids 2 to 3 hours before surgery
could be result of the dilution of acid secretions and/or decrease in their production by the decrease in anxiety and hunger levels. Gastric volume decrease in patients receiving fluids few hours before surgery could be due to gastric motility
stimulation by cold fluid entrance and/or physical stomach
distension 15,17,27,54 .
In spite of all knowledge obtained to date, it is not possible to
surely predict gastric contents. Healthy patients under prolonged fasting may, during surgery, present vomiting with
contents of previous day meal. Others may present
hypoglycemia, dehydration and irritability. However it seems
reasonable to conclude that unrestricted ingestion of clear
fluids for healthy patients 2 hours or more before surgery has
a more than acceptable risk/benefit ratio 7,8,11,21,55,56 .
The American Society of Anesthesiologists, through the ASA
Task Force on Preoperative Fasting 57, has developed practical guidelines for preoperative fasting and for the use of drugs
involved in decreasing gastric volume and acidity. Based on an
extensive literature review, guidelines are aimed at healthy patients of all ages submitted to elective procedures, and do not
include patients at increased aspiration risk. Such recommendations may be adopted, modified or rejected according to individual clinical needs and are subject to periodic reviews according to the evolution of knowledge on the subject.
Recommendations are summarized as follows (Table II):
Clear fluids (water, tea, coffee, fruit juice without pulp, all
without alcohol and with little sugar): 2 hours fasting for
all ages;
Breast milk: 4 hours fasting for neonates and infants;
Light diet (tea and toasts) and non breast milk: up to 6
hours fasting is accepted for children and adults;
Pediatric formula: 6 hours fasting for neonates and infants;
Solids: 8 hours fasting for children and adults.
Table II - Preoperative Fasting Recommendations according to ASA Task Force on Preoperative Fasting
Ingested Food
Minimum Fasting (h)
Clear fluids
Breast milk
Pediatric formula
Non breast milk
Light diet
Summary of Fasting Recommendations to Reduce the Risk of Pulmonary

Aspiration. From: Anesthesiology, 1999;90:896-905

Many investigators have studied the implementation of new

preoperative fasting guidelines to replace the old recommendation nothing by mouth after midnight. Ferrari 58 has
evaluated 51 institutions in the USA and Canada and has
concluded that the approach preconized by the American
Society of Anesthesiologists represents most pediatric institutions in North America. Investigations in the UK, Scotland, Germany and Norway have also shown that more flexible preoperative fasting measures have been adopted by
most institutions in those countries without increasing complication rates 59-62 .
Some points should also be mentioned:
Studies in adults have shown no difference in gastric contents
of patients chewing sugarless gums immediately before surgery 16,63 . Even so, Splinter 23 suggests 2 hours fasting for
chewing gum and sweets.
A recent study with healthy non obese pregnant women who
were not in labor, has not found difference in gastric contents
after the ingestion of 300 ml of water as compared to prolonged fasting 64 .
The American Society of Anesthesiologists Task Force on
Obstetrical Anesthesia 65 recommends that moderate clear
fluid ingestion may be allowed for pregnant women in uncomplicated labor. When there is other associated risk factor (diabetes, morbid obesity, difficult airway), or patients are at high
risk to evolve to C-section, fluid restriction should be determined in a case-by-case basis. As to solids, the committee
agrees that 8 hours or more for elective C-sections is the most
adequate period.
Labor patients should not ingest solids.
Mechanisms involved in increased pulmonary aspiration risk
in obese patients do not include increase in gastric contents
because it is not higher as compared to the volume of
non-obese patients. Other factors, such as intra-gastric, abdominal and lower esophageal sphincter pressures probably
play a more important role in aspiration pathophysiology of
obese patients 66 .
A c c o r d i n g t o t h e N o r we g i a n N a t i o n a l C o n s e n s u s ,
preanesthetic medication may be ingested by adults with 150
ml of water up to one hour before anesthesia. The same is true
for children but with the limitation of 75 ml of water 23 .
Gastric Acidity Decrease
Many clinical studies have been performed in Anesthesia
about the use of H2 receptor antagonists and proton pump
blockers in healthy patients to evaluate their effects on gastric volume and pH 67 .
A single 150 mg ranitidine dose few hours before anesthetic
induction significantly increases gastric pH, in addition to decreasing its volume 67-69 .
Protons pump blockers prescription, however, requires the
understanding of its pharmacology. Studies have shown that
such drugs are more effective if administered in two successive doses: one the night before and the other in the morning
of anesthesia 67-69 .
269
MORO
Although being possible to show that these drugs increase

gastric pH and decrease its volume, the ASA Task Force considers that there are no evidences supporting their routine
use in healthy patients, but only in risk patients, since there is
no proven decrease in aspiration, morbidity or mortality rate
with the use of such drugs in healthy patients 57 .
The efficacy of preoperative antacids to decrease gastric
acidity is proven but there are no evidences that these solutions act on gastric volume. Particulate antacids may increase the risk for pulmonary injury in case of aspiration and
should be avoided. So, preoperative antacids (non-particulate such as sodium citrate) should only be prescribed to risk
patients 57 .
Anti-emetics (e.g.: droperidol and ondansetron) are also
solely indicated for patients at higher risk for aspiration 57 .
Nasogastric Tube
Nasogastric tubes are commonly inserted in risk patients before anesthesia, aiming at stomach emptying. However, it
seems that upper and lower esophageal sphincters function
is impaired as compared to the function in patients without
nasogastric tubes 42,70 . Sellick recommends in his original
study 42 that the tube should be removed before anesthetic induction. However, two studies with cadavers have shown that
the efficacy of the Sellilcks maneuver is not decreased with
its presence 71,72 . So, the tube would act as a safe passage for
gastric contents when effective cricoid cartilage compression is applied. Based on these data, Smith 9 suggests that
the tube should be left in situ during rapid sequence induction
associated to Sellicks maneuver.
There are no significant differences in pulmonary aspiration
rate when different tube sizes are used 73 .
A cuff associated to the tube has been successfully used aiming at occluding the cardia, thus gastroesophageal reflux 74 .
This tube with gastric cuff has been studied together with laryngeal mask. It has been observed that the tube does not interfere with laryngeal mask insertion and that this would not
prevent tube insertion. So, this association represents a
good option for difficult airways manipulation in patients at
risk for aspiration 75 .
Cricoid Cartilage Pressure
Cricoid cartilage pressure (Sellicks maneuver) has become
universal practice during anesthetic induction in patients with
potentially full stomach 76 . Such maneuver, when correctly
performed, prevents gastric inflation in children 77 and adults
78,79
, in addition to increasing upper esophageal sphincter
tone 80 . Lower esophageal sphincter tone decreases with
such compression 81 , suggesting the presence of pharyngeal
mechanoreceptors promoting reflex relaxation of this
sphincter. This effect, however, does not seem to cause
gastroesophageal reflux 82 .
The incorrect application of the maneuver may deform cricoid
cartilage, close vocal cords and impair ventilation, especially
in women 83 . Strength applied should be sufficient to prevent
270
aspiration, but not so strong to cause airway obstruction or allow for esophageal rupture in case of vomiting. Cephalad and
backward direction of the strength applied seems to improve
laryngoscopic visualization 84 .
A major scenario to be considered is tracheal intubation failure in patients with full stomach under cricoid cartilage compression. In this situation, a laryngeal mask may help ventilation and oxygenation, but studies have shown that Sellicks
maneuver prevents its correct positioning 85,86 . So, if laryngeal mask is used during tracheal intubation failure, it may be
necessary to temporarily interrupt the maneuver to help ventilation, oxygenation and intubation through the laryngeal
mask. Interruption seems to be a reasonable option since
cricoid cartilage compression may become ineffective after
few minutes of application 87 .
EFFECTS OF DIFFERENT AIRWAY CONTROL
METHODS ON ASPIRATION RISK
Tracheal Intubation
Tracheal intubation is the most effective method to protect airways in anesthetized patients. However, some studies performed with intubated patients in intensive care units, have
shown that high volume and low pressure cuffs have allowed
the leakage of stain to the trachea 88,89. Mechanism involved
might be microaspiration through the glottis by small channels
between the cuff and tracheal mucosa 90. The lubrication of
cuffs with gel has significantly decreased leakage 90,91.
Laryngeal Mask
Laryngeal mask is associated to decrease in pressure barrier
represented by lower esophageal sphincter 92 . A study of patients under general anesthesia with positive pressure ventilation has shown that in the group using laryngeal mask there
has been a significant increase in gastroesophageal reflux as
compared to the group using tracheal tube with cuff 93 . There
is also reflux in patients under spontaneous ventilation and
laryngeal mask 94 . In fact, there are no significant differences
in regurgitation rate between groups spontaneously ventilating or under positive pressure ventilation 95,96 . Time for laryngeal mask removal at the end of general anesthesia seems to
influence reflux rate since those who had the mask removed
when able to spontaneously open their mouths had a lower incidence of reflux as compared to those who had their masks
removed before consciousness recovery 97 .
The development of a new laryngeal mask model, ProSeal
(Laryngeal Mask Company, Henley on Thames, UK), allows
the introduction of orogastric tube through an esophageal
opening for better gastric contents drainage, in addition to a
better gastric inflation blockade during positive pressure
ventilation. A recent study has shown that ProSeal is more effective than traditional laryngeal masks to prevent reflux,
what makes it a good option for patients at aspiration risk and
failed tracheal intubation 98,99 .
COPA and Combitube
Rapid Sequence
COPA (Cuffed Oropharyngeal Airway) is even less effective

than the laryngeal mask to prevent regurgitation 100 , thus not
being indicated for patients at aspiration risk.
Combitube, although protecting against regurgitation and allowing gastric contents drainage, requires a trained professional, since its use is associated to complications such as
sore throat, dysphagia and hematomas. So, in emergency
situations when airway protection is needed, combitube benefits should be counterbalanced with possible associated
complications 9 .
Rapid sequence induction traditionally involves preparing the

equipment, which should include, in addition to tracheal
intubation material, one aspirator, one backup laryngoscope
and equipment for intubation failure (laryngeal mask, fastrack,
fibroscope); 100% oxygen administration under facial mask
for 1 minute; short onset and duration intravenous opioid and
anesthetics (e.g.: propofol and alfentanil) and finally an also
short onset and duration neuromuscular blocker 3,104.
Succinylcholine has been used for 50 years by most anesthesiologists as the neuromuscular blocker of choice to intubate
full stomach patients, since it is the drug which best meets the
above-mentioned criteria. However, complications such as
malignant hyperthermia, fatal hyperkalemia, bradyarhythmias, intragastric and intraocular pressure increase have
encouraged the search for adepolarizing neuromuscular
blockers with shorter onset and duration, without
succinylcholine side-effects, hence, the introduction of
rocuronium as an alternative for patients under pulmonary aspiration risk. To assure onset and intubation conditions similar
to succinylcholine, preconized dose is 1 mg.kg-1 or more,
which implies longer duration, impairing its use for short procedures or those with possibilities of difficult intubation 105-108.
Succinylcholine or rocuronium, intubation with awaken patient, fibroscopy etc., all have advantages and disadvantages. The anesthesiologist should decide the best alternative on a case-by-case basis 109 .
OTHER PREVENTIVE GASTRIC

ASPIRATION MEASURES
Forecasting of Difficult Tracheal Intubation
The first step of difficult airway algorithm, developed by the
American Society of Anesthesiologists is the identification of
patients with potential difficult tracheal intubation 101 . In some
cases, such as facial trauma, some congenital syndromes or
morbid obesity, difficulty may be easily identified. However, in
less evident cases, intubation difficulty may only appear after
anesthetic induction, when protective reflexes are abolished,
and may expose patients to aspiration risks. So, the forecasting of difficult intubation may be done through some parameters, such as Mallampatis test 102 , thyroginean distance or
other tests available in the literature 103 .
Patients Positioning
Patients at risk for aspiration should be placed in the horizontal position with elevated dorsum approximately 30 with relation to the rest of the body. This position will prevent regurgitation, but if it happens, table position should be immediately
changed so that the head is positioned below the trunk, thus
preventing aspiration.
TRACHEAL INTUBATION WITH AWAKEN PATIENT OR
UNDER RAPID SEQUENCE INDUCTION
Awaken Patient
Once a potential difficult airway is identified, the safest
intubation method is with the patient awaken and under spontaneous ventilation 103 .
Tracheal intubation may be performed after mild sedation,
maintaining airways protective reflexes. Antisialogogues,
such as atropine or scopolamine, should be administered
and oropharynx should be topically anesthetized with spray
lidocaine (10%). Glossopharyngeal and upper laryngeal
nerves blockade might be useful for those mastering the
technique 101 .
ASPIRATION PNEUMONITIS
Pulmonary aspiration is defined as inhalation of oropharynx
or stomach contents through the larynx to low respiratory
tract 110,111 . Several pulmonary syndromes may be present after aspiration, depending on quantity and nature of the material. Aspiration pneumonitis (Mendelsons syndrome) is a
chemical injury caused by sterile gastric contents aspiration,
while aspiration pneumonia is an infection caused by inhalation of colonized material especially coming from
oropharynx. Other syndromes include mechanical airway obstruction, pulmonary abscess and chronic interstitial fibrosis
110,111
.
Gastric material aspiration causes intensive pulmonary inflammation. Patient may present with cough, wheezing,
tachypnea, cyanosis, pulmonary edema, hypoxemia and arterial hypotension, with rapid progression to respiratory distress syndrome and death. Many patients may present only
with cough or wheezing and decreased oxygen saturation associated to radiological evidences of aspiration 112 .
Treatment includes oxygen administration and/or ventilatory
support, when necessary. Preventive antibiotics are not indicated because they may turn patient susceptible to secondary infection by more resistant organisms. Antibiotics are indicated for patients with aspiration pneumonitis not resolved
48 hours after aspiration 113 . Steroids are not recommended
because multicentric randomized and controlled studies
have failed in proving their benefits 114,115 .
271
MORO
Bronchoscopy should be performed in patients under suspicion of solid material aspiration causing airway obstruction.
Pulmonary washing under direct view is also indicated for
solid material aspiration 3 .
CONCLUSIONS
Pulmonary gastric contents aspiration, although uncommon,
requires special preventive care. Recently developed preoperative fasting guidelines suggest shorter fasting periods, especially for fluids, allowing more comfort to patients and less
risk for hypoglycemia and dehydration, without increasing the
incidence of perioperative pulmonary aspiration. The routine
use of drugs decreasing gastric acidity and volume seems to
be indicated only for risk patients. The best way to protect airways against aspiration is still tracheal intubation. Other airways maintenance methods have been used but their efficacy
in preventing aspiration is still lower, although representing
major alternatives for tracheal intubation failure. Cricoid cartilage compression, rapid sequence induction or induction with
awaken patient, in addition to patients positioning, play an important role in preventing pulmonary aspiration.
REFERNCIAS - REFERENCES
01. Warner MA - Is pulmonary aspiration still an import problem in
anesthesia? Review article, Current Op Anaesthesiology,
2000;13:215-218.
02. Mendelson CL - The aspiration of stomach contents into the
lungs during obstetric anesthesia, Am J Obst Gynecol,
1946;52:191-205.
03. Ortenzi AV, D`Ottaviano CR - Jejum Pr-Operatrio e o Paciente
de Estmago Cheio em: Atualizao em Anestesiologia,
SAESP, 1996;94-106.
04. Olsson GL, Hallen B, Hambraeus-Jonzon K - Aspiration during
anaesthesia: a computer-aided study of 185,358 anaesthetics.
Acta Anaesthesiol Scand, 1986;30:84-92.
05. Mellin Olsen J, Fasting S, Gisvold SE - Routine preoperative
gastric emptying is seldom indicated. A study of 85,594 anaesthetics with special focus on aspiration pneumonia. Acta
Anaesthesiol Scand, 1996;40:1184-1188.
06. Warner MA, Warner ME, Weber JG - Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology, 1993;78:56-62.
07. Warner MA, Warner ME, Warner DO et al - Perioperative pulmonary aspiration in infants and children. Anesthesiology,
1999;90:66-71
08. Borland LM, Sereika SM, Woelfel SK et al - Pulmonary aspiration in pediatric patients during general anesthesia: incidence
and outcome. J Clin Anesth,1998;10:95-102.
09. Alexander NG, Graham S - Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesth Analg,
2001;93:494-513
10. Flick RP, Schears GJ, Warner MA - Aspiration in pediatric anesthesia: is there a higher incidence compared with adults? Current Op Anesth, 2002;15:323-327.
11. Department of Health and Social Security. Deaths due to complications of anaesthesia. In: Report on confidential enquirer into
maternal deaths in England and Wales. London: Her Majestys
Stationary Office, 1957-1998.
272
12. Roberts RB, Shirley MA - Reducing the risk of acid aspiration

during cesarean section. Anesth Analg, 1974;53:859-868.
13. Plourde G, Hardy JF - Aspiration pneumonia: assessing the risk
of regurgitation in the cat. Can Anesth Soc J, 1986;33:345-348.
14. Raidoo DM, Rocke DA, Brock-Utne JG et al - Critical volume for
pulmonary acid aspiration: reappraisal in a primate model. Br J
Anaesth, 1990;65:248-250.
15. Splinter WM, Schaefer JD - Unlimited clear fluid ingestion two
hours before surgery in children does not affect volume or pH of
stomach contents. Anaesth Intensive Care, 1990;18:522-526.
16. Soreide E, Holst-Larsen H, Veel T et al - The effects of chewing
gum on gastric contents prior to induction of general anesthesia.
Anesth Analg, 1995;80:985-989.
17. Macuco MV - Jejum pr-operatrio: validade de critrios. Rev
Bras Anestesiol, 1998;48:295-308.
18. Kallar SK, Everett LL - Potential risks and preventive measures
for pulmonary aspiration: new concepts in preoperative fasting
guidelines. Anesth Analg, 1993;77:171-182.
19. Hutchinson A, Maltby JR, Reid CR - Gastric fluid volume and pH
in elective inpatients. Part I: coffee or orange juice versus overnight fast. Can J Anaesth, 1988;35:12-15.
20. Maltby JR, Reid CR, Hutchinson A - Gastric fluid volume and pH
in elective inpatients. Part II: coffee or orange juice with
ranitidine. Can J Anaesth, 1988;35:16-19.
21. Schreiner MS, Triebwasser A, Keon TP - Ingestion of liquids
compared with preoperative fasting in pediatric outpatients . Anesthesiology, 1990;72:593-597.
22. Schreiner MS - Gastric fluid volume: is it really a risk factor for
pulmonary aspiration? Anesth Analg, 1998;87:754-756.
23. Splinter WM, Schreiner MS - Preoperative fasting in children.
Anesth Analg, 1999;89:80-89.
24. Andres JM, Mathias JR, Clench MH et al - Gastric emptying in infants with gastroesophageal reflux. Measurement with a technetium-99m-labeled semisolid meal. Dig Dis Sci, 1988;33:
393-399.
25. Ct CJ - Changing concepts in preoperative medication and
NPO status of pediatric patient, em: Barash PG - ASA Refresher
Courses in Anesthesiology, 1995;22:101-116.
26. Minami H, McCallum RW - The physiology and pathophysiology
of gastric emptying in humans. Gastroenterology, 1984;86:
1592-1610.
27. Agarwal A, Chari P, Singh H - Fluid deprivation before operation.
The effect of a small drink. Anaesthesia, 1989;44:632-634.
28. Moore JG, Christian PE, Coleman RE - Gastric emptying of varying meal weight and composition in man. Evaluation by dual liquid and solid-phase isotopic method. Dig Dis Sci, 1981;26:
16-22.
29. Warde D - Fasting children for anaesthesia and surgery. Ir Med
J, 1991;84:4-5.
30. Phillips S, Daborn AK, Hatch DJ - Preoperative fasting for paediatric anaesthesia. Br J Anaesth, 1994;73:529-536.
31. Moukarzel AA, Sabri MT - Gastric physiology and function: effects of fruit juices. J Am Coll Nutr, 1996;15:(Suppl5):18S-25S.
32. Bailey CR - Gastroesophageal reflux and aspiration of gastric
contents in anesthetic practice. Survey Anesth,
2002;46:137-138.
33. Kahrilas PJ, Dodds WJ, Dent J et al - Effects of sleep, spontaneous gastroesophageal reflux and a meal on upper esophageal
sphincter pressure in normal human volunteers.
Gastroenterology; 1987;92:466-471.
34. Eriksson LI, Sundman E, Olsson R et al - Functional assessment of the pharynx at rest and during swallowing in partially
paralyzed humans: simultaneous videomanometry and
mechanomyography of awake human volunteers.
Anesthesiology, 1997;87:1035-1043.

35. Sundman E, Witt H, Olsson R et al - The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and
simultaneous manometry after atracurium, . Anesthesiology,
2000;92:977-984
36. Berg H - Is residual neuromuscular block following pancuronium
a risk factor for postoperative pulmonary complications? Acta
37. Coranza R, Nandwani N, Tring JP et al - Upper airway reflex sensitivity following general anaesthesia for day-case surgery. Anaesthesia, 2000;55:367-370.
38. Langton JA, Murphy PJ, Barker P et al - Measurement of the sensitivity of the upper airway reflexes. Br J Anaesth, 1993;70:
126-130.
39. Murphy PJ, Langton JA, Barker P et al - Effect of oral diazepam
on the sensitivity of the upper airway reflexes. Br J Anaesth,
1993;70:131-134.
40. Erskine RJ, Murphy PJ, Langton JA et al - Effect of age on the
sensitivity of upper airway reflexes. Br J Anaesth, 1993;70:
574-575.
41. Mc Intyre JWR - Evolution of 20th century attitudes to prophylaxis
of pulmonary aspiration during anaesthesia. Can J Anaesth,
1998;45:1024-1030.
42. Sellick BA - Cricoid pressure to control regurgitation of stomach
contents during induction of anesthesia . Lancet, 1961;19:
404-406.
43. Gallimore SC, Hoite RW, Ingram GS et al - Questionnaire in the
report of the national confidential enquiry into perioperative
deaths 1994-1995. London: National Confidential Enquiry into
Perioperative Death, 1997.
44. Singh O - Effect of preoperative fasting in children and adults.
Midle East J Anesthesiol, 1985;8:235-239.
45. Bush GH, Steward DJ - Severe hypoglycemia associated with
preoperative fasting and intraoperative propranolol. A case report and discussion. Paediatr Anaesth, 1996;6:415-417.
46. Maekawa N, Mikawa K, Yaku H et al - Effects of 2, 4 and 12 hours
fasting intervals on preoperative gastric fluid pH and volume,
and plasma glucose and lipid homeostasis in children. Acta
47. Shirley DJ, Mathieu A, Gunter J - Effects of fasting interval on
risk factors for pulmonary aspiration in pediatric patients: a
meta-analysis. Anesth Analg, 1995;80:S440.
48. Guyton AC, Hall JE - Tratado de Fisiologia Mdica, 10 Ed, Rio
de Janeiro, Guanabara Koogan, 2002;64:686-701.
49. Manchikanti L, Colliver JA, Marrero TC et al - Assessment of
age-related acid aspiration risk factors in pediatric, adult, and
geriatric patients. Anesth Analg, 1985;64:11-17.
50. Ong BY, Palahniuk RJ, Cumming M - Gastric volume and pH in
out-patients. Can Anaesth Soc J, 1978;25:36-39.
51. Cote CJ, Goudsouzian NG, Liu LM et al - Assessment of risk factors related to the acid aspiration syndrome in pediatric patients-gastric pH and residual volume. Anesthesiology, 1982;
56:70-72.
52. Sutherland AD, Maltby JR, Sale JO et al - The effect of preoperative oral fluid and ranitidine on gastric fluid volume and pH. Can
J Anaesth, 1987;34:117-121
53. Splinter WM, Stewart JA, Muir JG - The effect of preoperative apple juice on gastric contents, thirst and hunger in children. Can J
Anaesth, 1989;36:55-58.
54. Goresky GV, Maltby JR - Fasting guidelines for elective surgical
patients. Can J Anaesth, 1990;37:493-495.
55. Litman RS, Wu CL, Quinlivan JK - Gastric volume and pH in infants fed clear liquids and breast milk prior to surgery. Anesth
Analg, 1994;79:482-485.
56. Read MS, Vaughan RS - Allowing preoperative patients to drink:

effects on patients` safety and comfort of unlimited oral water
until 2 hours before anesthesia. Acta Anaesthesiol Scand,
1991;35:591-595.
57. American Society of Anesthesiologists Task Force on Preoperative Fasting. Practice guideline for preoperative fasting. and use
of pharmacology agents to reduce the risk of pulmonary aspiration: application to health patients undergoing elective procedures. Anesthesiology, 1999;90:896-905.
58. Ferrari LR, Rooney FM, Rockoff MA - Preoperative fasting practices in pediatrics. Anesthesiology, 1999;90:978-980.
59. Fasting S, Soreide S, Raeder JC - Changing preoperative fasting policies. Impact of a national consensus. Acta Anaesthesiol
Scand, 1998;42:1188-1191.
60. Emerson BM, Wrigley SR, Newton M - Preoperative fasting for
paediatric anaesthesia. A survey of current practice. Anaesthesia, 1998;53:326-330.
61. Green CR, Pandit SK, Schork MA - Preoperative fasting time: is
the traditional policy changing? Results of a national survey.
Anesth Analg, 1996;83:123-128.
62. Haas U, Motsch J, Schreckenberger R et al - Pramedication and
preoperative fasting in pediatric anesthesia. Results e survey.
Anaesthetist, 1998;47:838-843.
63. Dubin AS, Jense HG, Mc Crane JM et al - Sugarless gum chewing before surgery does not increase gastric volume or acidity.
Can J Anaesth, 1994;41:603-606.
64. Wong CA, Loffredi M, Ganchiff J - Gastric emptying of water in
term pregnancy. Anesthesiology, 2002;96:1395-1400.
65. Practice Guideline for obstetrical anesthesia: a report by the
American Society of Anesthesiologists Task Force on Obstetrical Anesthesia. Anesthesiology, 1999;90:600-611.
66. Juvin P, Fevre G, Merouche M et al - Gastric residue is not more
copious in obese patients. Anesth Analg, 2001;93:1621-1622.
67. Nishina K, Mikawa K, Takao Y et al - A comparison of
rabeprazole, lansoprazole, and ranitidine for improving preoperative gastric fluid property in adults undergoing elective surgery. Anesth Analg, 2000;90:717-721.
68. Nishina K, Mikawa K, Maekawa N et al - A comparison of
lanzoprazole, omeprazole, and ranitidine for reducing preoperative gastric secretion in adult patients undergoing elective surgery. Anesth Analg, 1996;82:832-836.
69. Escolano F, Castano J, Lopez R et al - Effects of omeprazole,
ranitidine, famotidine and placebo on gastric secretion in patients undergoing elective surgery. Br J Anaesth, 1992;69:
404-406.
70. Manning B, Mc Greal G, Winter DC et al - Nasogastric intubation
causes gastroesophageal reflux in patients undergoing elective
laparotomy. Br J Surg, 2000;87:637.
71. Vanner RG, Pryle BJ - Regurgitation and oesophageal rupture
with cricoid pressure: a cadaver study. Anaesthesia, 1992;47:
732-735.
72. Salem MR, Joseph NJ, Heyman HJ et al - Cricoid compression is
effective in obliterating the esophageal lumen in the presence of
a nasogastric tube. Anesthesiology, 1985;63:443-446.
73. Ferrer M, Bauer TT, Torres A et al - Effect of nasogastric tube size
on gastroesophageal reflux and microaspiration in intubated
patients. Ann Intern Med, 1999;130:991-994.
74. Roewer N - Can pulmonary aspiration of gastric contents be prevented by balloon occlusion of the cardia? A study with a new
nasogastric tube. Anesth Analg, 1995;80:378-383.
75. Schwarzmann GF, Wurmb T, Grein CA et al - Difficult airway
management: combination of the laryngeal mask airway with a
new gastric balloon tube. Anesthesiology, 1998;89:1237A.
273
MORO
76. Thwaites AJ, Rice CP, Smith I - Rapid sequence induction: a
questionnaire survey of its routine conduct and continued management during a failed intubation. Anaesthesia, 1999;54:
376-381.
77. Salem MR, Wong AY, Mani M et al - Efficacy of cricoid pressure in
preventing gastric inflation during bag-mask ventilation in pediatric patients. Anesthesiology, 1974;40:96-98.
78. Lawes EG, Campbell I, Mercer D - Inflation pressure, gastric
insufflation and rapid sequence induction. Br J Anaesth,
1987;59:315-318.
79. Asai T, Barclay K, McBeth C et al - Cricoid pressure applied after
placement of the laryngeal mask prevents gastric insufflation
but inhibits ventilation. Br J Anaesth, 1996;76:772-776.
80. Vanner RG, O`Dwyer JP, Pryle BJ et al - Upper oesophageal
sphincter pressure and the effect of cricoid pressure. Anaesthesia, 1992;47:95-100.
81. Toumadre JP, Chassard D, Berrada KR et al - Cricoid cartilage
pressure decreases lower esophageal sphincter tone. Anesthesiology, 1997;86:7-9
82. Skinner HJ, Bedforth NM, Girling KJ et al - Effect of cricoid pressure on gastroesophageal reflux in awake subjects. Anaesthesia, 1999;54:798-808.
83. Palmer JH, Mac G Ball DR - The effect of cricoid pressure on the
cricoid cartilage and vocal cords: an endoscopic study in anaesthetized patients. Anaesthesia, 2000;55:263-268.
84. Vanner RG, Clarke P, Moore WJ et al - The effect of cricoid pressure and neck support on the view at laringoscopy. Anaesthesia, 1997;52:896-900.
85. Asai T, Barclay K, Power I et al - Cricoid pressure impedsd placem e n t o f t h e l a r y n g e a l m a s k a i r w a y. B r J A n a e s t h ,
1995;74:521-525.
86. Aoyama K, Takenaka I, Sata T et al - Cricoid pressure impedes
positioning and ventilation through the laryngeal mask airway.
Can J Anaesth, 1996;43:1035-1040.
87. Meek T, Vincent A Duggan JE - Cricoid pressure: can protective
force be sustained? Br J Anaesth, 1998;80:672-674.
88. Young PJ, Basson C, Hamilton D et al - Prevention of tracheal
aspiration using the pressure-limited tracheal tube cuff. Anaesthesia, 1999;54:559-563
89. Young PJ, Ridley AS - Ventilator-associated pneumonia. Diagnosis, pathogenesis and prevention. Anaesthesia,
1999;54:1183-1197.
90. Young PJ, Rollinson M, Downward G et al - Leakage of fluid past
the tracheal tube cuff in a benchtop model. Br J Anaesth,
1997;78:557-562.
91. Blunt MC, Young PJ, Patil A et al - Gel lubrification of the tracheal
tube cuff reduces pulmonary aspiration. Anesthesiology,
2001;95:377-381
92. Rabey PG, Murphy PJ, Langton JA et al - Effect of the laryngeal
mask airway on lower oesophageal sphincter pressure in patients during general anaesthesia. Br J Anaesth,
1992;69:346-348
93. Valentine J, Stakes AF, Bellamy MC - Reflux during positive
pressure ventilation through the laryngeal mask. Br J Anaesth,
1994;73:543-544.
94. Owens TM, Robertson P, Twomey C et al - The incidence of
gastroesophageal reflux with the laryngeal mask: a comparison
with the face mask using esophageal lumen pH electrodes.
Anesth Analg, 1995;80:980-984.
95. Skinner HJ, Ho BY, Mahajan RP - Gastro-oesophageal reflux
with the laryngeal mask during day-case gynaecological laparoscopy. Br J Anaesth, 1998;80:675-676.
274
96. Akhtar TM, Street MK - Risk of aspiration with the laryngeal

mask. Br J Anaesth, 1994;72:447-450.
97. Cheong YP, Park SK, Son Y et al - Comparison of incidence of
gastroesophageal reflux and regurgitation associated with timing of removal of the laryngeal mask airway: on appearance of
signs of rejection versus after recovery consciousness. J Clin
Anesth, 1999;11:657-662.
98. Brain AI, Verghese C, Strube PJ - The LMA ProSeal - a laryngeal mask with an oesophageal vent. Br J Anaesth,
2000;84:650-654.
99. Keller C, Brimacombe J - Mucosal pressure and oropharyngeal
leak pressure with the ProSeal versus the laryngeal mask airway in anaesthetized paralyzed patients. Br J Anaesth,
2000;85:262-266.
100. Brimacombe J, Keller C - The cuffed oropharyngeal airway vs
the laryngeal mask airway: a randomized cross-over study of
oropharyngeal leak pressure and fibreoptic view in paralyzed
patients. Anaesthesia, 1999;54:683-685.
101. Lutke C - Abordagem Via Area Difcil, em: Atualizao em
Anestesiologia, SAESP 2000;5:126-139.
102. Mallampati SR, Gatt SP, Gugino LD et al - A clinical signal to
predict difficult tracheal intubation: a prospective study. Can
Anaesth Soc J, 1985;32:429-434.
103. Benumof JL - The ASA Dificult Airway Algorithm: new
thoughts/considerations. Annual Refresher Course Lectures,
1999;134:1-7.
104. Van Maren GA - Emergency Anaesthesia in Unprepared Patient, em: Prys-Roberts C, Brown BR - International Practice of
Anesthesia. Oxford: Butterworth-Heinemann; 1996;1291-1297.
105. Almeida MCS - Succinilcolina 50 anos de soberania. Rev Bras
de Anestesiol, 2002;52:513-516.
106. Kirkegaard-Nielsen H, Caldwell JE, Berry PD et al - Rapid tracheal intubation with rocuronium: a probability approach to determining dose. Anesthesiology, 1999;91:131-136.
107. Sparr HJ, Mitterschiffthaier G - Are only large doses of
rocuronium an alternative to succinylcholine for rapid-sequence
induction? Anesthesiology, 1994;80:1411-1412.
108. Heier T, Caldwell JE - Rapid tracheal intubation with large-dose
rocuronium: a probability-based approach. Anesth Analg,
2000;90:175-179.
109. Engbaek J - Succinylcholine or rocuronium for rapid sequence
induction. Acta Anaesthesiol Scand, 2000;44:494-495.
110. Irwin RS - Aspiration, em: Irwin RS, Cerra FB, Rippe JB - Irwin
and Rippe`s Intensive Care Medicine. 4th Ed, Philadelphia.
Lippincott-Raven, 1999;685-692.
111. Caseira HA, Niederman MS - Aspiration Pneumonia, Lipoid
Pneumonia and Lung Abscess, em: Baum GL, Crapo JD, Celli
BR - Textbook of Pulmonary Diseases, 6th Ed, Philadelphia.
Lippincott-Raven, 1998;645-655.
112. Gibbs CP, Modell JH - Pulmonary Aspiration of Gastric Contents: Pathophysiology, Prevention and Management, em:
Miller RD - Anesthesia, 4th Ed, New York; Churchill Livingstone,
1994;1437-1464.
113. Marik PE - Aspiration pneumonitis and aspiration pneumonia.
N Engl J Med, 2001;344:665-671.
114. Bernard GR, Luce JM, Sprung CL et al - High-doses
corticosteroids in patients with tie adult respiratory distress syndrome. N Engl J Med, 1987;317:1565-1570.
115. Bone RC, Fisher Jr CJ, Clemmer TP et al - Early
methylprednisolone treatment for septic syndrome and the
adult respiratory distress syndrome. Chest, 1987;92:
1032-1036.

RESUMEN
Moro ET - Prevencin de la Aspiracin Pulmonar del Contenido
Gstrico
JUSTIFICATIVA Y OBJETIVOS: No obstante de la baja
incidencia, la aspiracin pulmonar del contenido gstrico
puede tener consecuencias devastadoras para el individuo. La
disminucin en la funcin del esfnter esofgico y de los reflejos
protectores de las vas areas causada por la depresin de la
conciencia, predispone los pacientes a esta grave
complicacin. En este articulo, se realizo una revisin de los
aspectos fisiolgicos asociados al reflujo gastroesofgico,
bien como los mtodos utilizados para prevenirlo.
C ON T E N ID O: F u e r o n h e c h o s c o m e n ta r i o s s o b r e l o s
mecanismos envueltos en la aspiracin del contenido gstrico,
sus consecuencias y mtodos de prevencin, incluyendo
recientes guas de ayuno pre-operatorio elaborados despus
de revisin de la literatura, el uso racional de drogas que actan

y el pH y volumen gstrico, y, finalmente, el efecto de diferentes

mtodos de manutencin de la va area en la prevencin de la
aspiracin pulmonar.
CONCLUSIONES: La aspiracin pulmonar del contenido
gstrico, no obstante sea poco frecuente, exige cuidados
especiales para su prevencin. Guas de ayuno pre-operatorio
elaborados recientemente sugieren perodos menores de
ayuno, principalmente para lquidos, permitiendo ms
comodidad a los pacientes y menor riesgo de hipoglicemia y
deshidratacin, sin aumentar la incidencia de aspiracin
pulmonar perioperatoria. El uso rutinario de drogas que
diminuyen la acidez y volumen gstrico parece estar indicado
apenas para pacientes de riesgo. El mejor mtodo de
proteccin de la va area contra la aspiracin continua siendo
la intubacin traqueal. Otros mtodos de manutencin de la va
area estn siendo adoptados, ms la eficacia en la prevencin
de la aspiracin aun es inferior, aun cuando representen
importante alternativa en casos de falla de intubacin traqueal.
275

Prevenção Da Aspiração Pulmonar Do Conteúdo Gástrico (Rev Bras Anestesiol, 2004)

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Prevenção Da Aspiração Pulmonar Do Conteúdo Gástrico (Rev Bras Anestesiol, 2004)

Uploaded by

Copyright:

Available Formats

Rev Bras Anestesiol

2004; 54: 2: 261 - 275

Preveno da Aspirao Pulmonar do Contedo Gstrico *

Unitermos: COMPLICAES: aspirao pulmonar

ecentes estudos sugerem que a aspirao pulmonar

Revista Brasileira de Anestesiologia

monar do contedo gstrico durante o parto com anestesia

estudo do Scandinavian Teaching Hospital observou que a

Unidade de terapia intensiva

Flick: Curr Opin Anesthesiol, 2002;15:323-327

Grandes estudos retrospectivos realizados em diferentes

anos. Esta diminuio , sem dvida, resultado da transio

PREVENO DA ASPIRAO PULMONAR DO CONTEDO GSTRICO

Esfncter Esofgico Inferior

e aspirao da sonda nasogstrica antes da induo da

cadas ou rejeitadas de acordo com as necessidades clnicas

Jejum Mnimo (h)

Lquido sem resduos

Summary of Fasting Recommendations to Reduce the Risk of Pulmonary

Muitos investigadores tm estudado a implementao dos

que h outro fator de risco associado (diabetes, obesidade

PREVENO DA ASPIRAO PULMONAR DO CONTEDO GSTRICO

res esofgicos superior e inferior fica comprometida quando

EFEITO DOS DIFERENTES MTODOS DE CONTROLE

quando a proteo da via area necessria, os benefcios

Os pacientes com risco de aspirao devem ser colocados

INTUBAO TRAQUEAL COM PACIENTE ACORDADO

Revista Brasileira de Anestesiologia

PREVENTION OF PULMONARY GASTRIC CONTENTS ASPIRATION

Prevention of Pulmonary Gastric Contents

Mayo Clinic studies have observed similar incidence in adults

Intensive care unit

Flick: Curr Opin Anesthesiol, 2002;15:323-327

In a Mayo Clinic study 6 , 27% of pulmonary aspiration patients

PREVENTION OF PULMONARY GASTRIC CONTENTS ASPIRATION

In general, stomach acid secretion production rate is 0.6

Minimum Fasting (h)

Non breast milk

Summary of Fasting Recommendations to Reduce the Risk of Pulmonary

Revista Brasileira de Anestesiologia

Many investigators have studied the implementation of new

Although being possible to show that these drugs increase

PREVENTION OF PULMONARY GASTRIC CONTENTS ASPIRATION

COPA and Combitube

COPA (Cuffed Oropharyngeal Airway) is even less effective

Rapid sequence induction traditionally involves preparing the

OTHER PREVENTIVE GASTRIC

12. Roberts RB, Shirley MA - Reducing the risk of acid aspiration

PREVENTION OF PULMONARY GASTRIC CONTENTS ASPIRATION

56. Read MS, Vaughan RS - Allowing preoperative patients to drink:

96. Akhtar TM, Street MK - Risk of aspiration with the laryngeal

Revista Brasileira de Anestesiologia

PREVENTION OF PULMONARY GASTRIC CONTENTS ASPIRATION

Revista Brasileira de Anestesiologia

y el pH y volumen gstrico, y, finalmente, el efecto de diferentes

You might also like